IOM Issues Recommendations on Medicare QIOs
The responsibility for investigating complaints from Medicare beneficiaries should be shifted from Quality Improvement Organizations to a few national or regional contractors, the Institute of Medicine said in a report on Thursday, the Washington Post reports.
CMS pays about $300 million annually to 53 private contractors to investigate beneficiary complaints, evaluate quality and work with physicians and hospitals to improve care. According to the report, QIOs have failed to support beneficiary rights and have conflicts of interest that might lead them to make decisions that benefit physicians and hospitals over beneficiaries.
"The evidence indicates that QIOs have not publicized beneficiary rights effectively and have issued fewer provider sanctions in recent years," the report says. It continues, "This may be the result of inherent conflicts of interest: QIOs consider providers, not beneficiaries, to be their primary clients, and a QIO may not want to antagonize the providers" (Gaul, Washington Post, 3/10).
QIOs should focus solely on working with physicians and hospitals to improve care and should not be responsible for investigating complaints, the report recommends (Carey, CQ HealthBeat, 3/9). The report says QIOs should increase their role of providing technical assistance to hospitals and providers to implement systems for publicly reporting outcomes and pay-for-performance standards.
In addition, the report calls for CMS to conduct more "rigorous" independent studies to evaluate QIOs and "guide future decisions about the program," noting that there currently is no "conclusive evidence" available to measure QIOs' work. QIOs also should diversify their boards, which now are "heavily dominated by physicians," to include more consumers, the report says (Washington Post, 3/10).
Further, "Making public the names of the members of QIO boards and disclosing information on their compensation would increase transparency of operations and foster greater trust," the report states. Congress might need to increase funding for the QIO program to implement the changes, it says (CQ HealthBeat, 3/9).
Congressional action might also be required to permit the release of the names and outcomes of providers that work with QIOs and to increase disclosure of details of QIO investigations, the Post reports (Washington Post, 3/10).
Steven Schroeder of the University of California-San Francisco and member of the IOM panel that prepared the report, said, "The role of QIOs should be to improve health care practice rather than to supervise or regulate it" (CQ HealthBeat, 3/9).
Stephen Shortell, dean of the School of Public Health at the University of California-Berkeley, added, "Many of the [QIO] boards are frozen in the 1960s or 1970s, is one way to put it. We feel quite strongly about this and are calling for the upgrading or modernization." He said IOM "would like to see more nurses, pharmacists ... and consumers" on QIO boards (Washington Post, 3/10).
Barry Straube, acting chief medical officer at CMS, said the agency finds the recommendation to shift the responsibility for complaint investigations from QIOs to fewer contractors "a promising approach that [CMS] will evaluate promptly as part of its ongoing review of the program" (CQ HealthBeat, 3/9).
Jonathan Sugarman, past president of the American Health Quality Association, said the recommendation to shift the responsibility for complaint investigations from QIOs "deserves substantially more analysis." Sugarman said it is not "totally inconsistent" for QIOs to have providers and beneficiaries as clients.
AHQA recently acknowledged problems with the complaint process and called for reforms (Washington Post, 3/10).
David Schulke, executive vice president of AHQA, said, "IOM may inadvertently take us back to the days when someone is doing complaints ... who does not understand quality at the system level." Schulke said case reviews account for about 38% of QIO revenues and other types of beneficiary complaints account for an additional 4% (CQ HealthBeat, 3/9).